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BMJ Case Rep. 2014 May 2;2014. pii: bcr2013202639. doi: 10.1136/bcr-2013-202639.  A Lilliputian army under the floorboards: persistent delirium with complete though prolonged recovery.  Wakefield D1, Thompson L, Bruce S.  1East Sussex NHS Trust, St Leonards-on-Sea, UK.

We report the case of an 83-year-old man who presented with a history of fluctuating delirium of insidious onset, secondary to an amoebic liver abscess more than 30 years after acute exposure. We describe a 2-year clinical journey that started with a fall and was additionally complicated by severe weight loss and acute kidney injury (AKI). The likely prognosis for such a combination of comorbidities in an older person is for lasting morbidity, institutionalisation and significant mortality. However, the case demonstrates that with timely assessment and care complete recovery is possible though it may take many months. It reminds us of the catalytic implications of falls for older persons and to maintain a differential diagnostic approach to delirium of insidious onset avoiding misdiagnosis as dementia with which it may be associated. Our case report includes extracts from the patient's own account providing added insight into such experiences.

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The patient's health problems began in late July 2009 when he tripped and fell in his bedroom at home while getting up during the night. He injured his head and neck but did not lose consciousness and there was no abdominal injury. Prior to this he had been fully independent, living at home with his wife and still working as a writer. After the fall he experienced gradually increasing fatigue with anorexia and dysphagia. Two months later he experienced the onset of delirium and impaired mobility.

Extracts from his diary and accounts from his family provide additional insight into his decline following the fall:

“It all followed my head-banging, neck-twisting fall”.

“According to my diary, 16th October I ‘felt awful’. ‘Can't bear the smell of food’. I had become unsteady on my feet. I had the first of my hallucinations: the Italian army coming to steal my notebooks. Followed by a workforce of little people making something beneath the floorboards. By 24th October my handwriting becomes increasingly shaky. I insisted that 1st November was Armistice Day. On 3rd November I am ‘as weak as a kitten’.”

“6th December, reportedly I went through the house convinced I was back in the army, allocating rooms for my platoon, becoming furious when I discovered there were not enough. My family called the emergency services. I remember awareness of being unable to answer straightforward questions.”

Medical summary on presentation to Conquest Hospital December 2009: the patient was noted to be disorientated in time with impaired short-term memory, his Abbreviated Mental Test Score (AMTS) was 7/10. He also reported difficulties with concentration and his family emphasised the fluctuating nature of his mental state. During the period following the fall the only change in medication was a course of antibiotics for a chest infection in September 2009. It was noted that his work as a foreign and war correspondent involved an extensive travel history going back 58 years..............

Abdominal ultrasound showed a well-circumscribed cystic mass measuring 206×167× 129 mm, consistent with an abscess within the right lobe of the liver. This was confirmed by abdominal CT scan which showed no signs of malignancy. CT head scan showed no focal abnormalities. Amoebic serology was positive: The patient was transferred to University College London Hospital (UCLH) where the abscess was drained and, after a month, he was discharged home to complete a course of paromomycin......................

Further extracts from the patient's diary document his progress:

“After my admission to hospital I became convinced an American multi-millionaire was in charge and that the nurses were holding illicit parties. On my transfer to UCLH I believed that I was taking part in experiments to transfer patients between hospitals by cable car. Convinced that I was being transferred to a military hospital to help train special forces troops for a secret mission. I insisted to those attempting to calm me that their assurances were all part of the cover story. Once settled into UCLH, I was taking part in survival exercises in Mongolia.”

“After I was discharged home the little people returned to beaver away under the floor boards.”

Anorexia and dysphagia were prominent from the onset of his symptoms. Prior to his fall his weight was steady at around 110 kg. By the time of his admission to Conquest Hospital his weight had declined to 90 kg and on review in outpatients following discharge from UCLH his weight was noted to be 77 kg. This represents a loss of more than 20% of his usual body weight which persisted despite a period of nasogastric feeding and supplements prescribed on discharge. Oesophago-gastro-duodenoscopy as well as CT head was normal. Speech and language assessment identified pharyngeal dysphagia which had resolved by April 2010. By follow-up in March 2011 his appetite had returned to normal, he was independently mobile and finishing a book that he had been working on prior to his illness. However he did not regain the weight he had lost until August 2011. Two years further on from his recovery, the patient remains well and his latest book has just been published (August 2013).

PMID:  24792019